The adjunctive use of host modulators in non-surgical periodontal therapy. A systematic review of randomized, placebo-controlled clinical studies

New tendencies in non-surgical periodontal therapy

The aim of this review was to update the evidence of new approaches to non-surgical therapy (NSPT) in the treatment of periodontitis. Preclinical and clinical studies addressing the benefits of adjunctive antimicrobial photodynamic therapy, probiotics, prebiotics/synbiotics, statins, pro-resolving mediators, omega-6 and -3, ozone, and epigenetic therapy were scrutinized and discussed. Currently, the outcomes of these nine new approaches, when compared with subgingival debridement alone, did not demonstrate a significant added clinical benefit. However, some of these new alternative interventions may have the potential to improve the outcomes of NSPT alone. Future evidence based on randomized controlled clinical trials would help clinicians and patients in the selection of different adjunctive therapies.

Probiotics in the Management of Gingivitis and Periodontitis. A Review

In the management of intestinal health problems, the targeted use of probiotic microorganisms is a common therapeutic measure with a long-standing tradition. In clinical dentistry however, probiotics-based therapy is still a rather new and developing field, whose usefulness for the control of gingivitis and periodontitis has been questioned by recent meta-analyses and systematic reviews. The purpose of the subsequent descriptive review is to provide an introduction to the concept of probiotic microorganisms and their multifaceted health-promoting interactions with the human host and microbial competitors, followed by a detailed comparison of the results of available controlled clinical trials assessing the use of probiotics in the control of gingival and periodontal inflammations. It aims at contributing to a deeper understanding of the unique capabilities of probiotics to resolve chronic plaque-induced inflammation even in the absence of mechanical plaque control and will discuss how possible misconceptions about the rationale for using probiotics may have led to the present controversies about their usefulness as a therapeutic option.

Minimally Invasive Periodontology: A Treatment Philosophy and Suggested Approach

Severe periodontitis is a highly prevalent dental disease. With the advent of implant dentistry, teeth are often extracted and replaced. Periodontal surgery, where indicated, could also result in increased trauma to the patient. This literature review discusses different treatment modalities for periodontitis and proposes a treatment approach emphasizing maximum preservation of teeth while minimizing morbidity to the patient. Scientific articles were retrieved from the MEDLINE/PubMed database up to January 2021 to identify appropriate articles that addressed the objectives of this review. This was supplemented with hand searching using reference lists from relevant articles. As tooth prognostication does not have a high predictive value, a more conservative approach in extracting teeth should be abided by. This may involve repeated rounds of nonsurgical periodontal therapy, and adjuncts such as locally delivered statin gels and subantimicrobial-dose doxycycline appear to be effective. Periodontal surgery should not be carried out at an early phase in therapy as improvements in nonsurgical therapy may be observed up to 12 months from initial treatment. Periodontal surgery, where indicated, should also be minimally invasive, with periodontal regeneration being shown to be effective over 20 years of follow-up. Biomarkers provide an opportunity for early detection of disease activity and personalised treatment. Quality of life is proposed as an alternative end point to the traditional biomedical paradigm focused on the disease state and clinical outcomes. In summary, minimally invasive therapy aims to preserve health and function of the natural dentition, thus improving the quality of life for patients with periodontitis.

Clinical efficacy of subgingivally delivered propolis as an adjuvant to nonsurgical periodontal treatment of periodontitis: A systematic review and meta-analysis

This systematic review and meta-analysis evaluated randomized and nonrandomized studies that assessed the effect of local subgingival propolis as an adjunct to nonsurgical periodontal therapy (NSPT) in the treatment of periodontitis. A detailed search was carried out in Cochrane Library, Embase, LILACS, LIVIVO, PubMed, Scopus, and Web of Science, with no time or language restrictions. A grey literature search was also conducted. The methodology of included studies was evaluated by the Cochrane RoB2 tool. The certainty of each clinical outcome was assessed by the GRADE system. Meta-analyses of mean difference were conducted using the random-effects model, through RevMan 5.4 software. Six studies met the eligibility criteria to be synthesized in the qualitative analysis, and three studies were included in the meta-analysis. The subgingival application of propolis as an adjunct to NSPT improved probing pocket depth (PPD), clinical attachment level (CAL), and bleeding on probing (BOP) in most of the assessed studies. The overall mean difference in PPD reduction was 1.49 mm, 30-45 days after treatment, and 0.8 mm, 90 days after treatment, with very low level of certainty. The overall bias was scored as high risk for all included studies. The adjunctive use of locally delivered propolis associated to NSPT to treat periodontitis may improve periodontal clinical parameters, compared with NSPT alone/placebo. However, the evidence was not strong enough to safely base any clinical recommendation.

Systematic review and meta-analysis on the adjunctive use of host immune modulators in non-surgical periodontal treatment in healthy and systemically compromised patients

Considering the central role of inflammation in the pathogenesis of periodontitis, the combination of NSPT with different agents that can modulate the host immune-inflammatory response has been proposed to enhance the outcomes of NSPT. The aim of this paper is to systematically review the literature on the efficacy of systemic host modulators (HMs) as adjuncts to non-surgical periodontal therapy (NSPT) in improving pocket depth (PD) reduction and clinical attachment level (CAL) gain in healthy and systemically compromised patients. RCTs with ≥ 3 months follow-up were independently searched by two reviewers. Meta-analysis was performed when ≥ 3 studies on the same HM were identified. The quality of the evidence was rated according to the GRADE approach to rate the certainty of evidence. 38 articles were included in the qualitative assessment and 27 of them were included in the meta-analysis. There is low/very low evidence that the adjunctive use of sub-antimicrobial dose of doxycicline, melatonin and the combination of omega-3 and low dose aspirin (in type 2 diabetic patients) to NSPT would improve PD and/or CAL. Conflicting evidence is available on the efficacy of probiotics. Future studies controlling for confounding factors, using composite outcomes to define the endpoint of therapy and considering not only the patient- but also as the site-specific effect of systemic HMs are warranted. The dosage, posology and long-term effect of HMs still need to be clarified, also in association to the presence of systemic conditions potentially affecting the response to HMs administration.

Probiotic therapy for periodontal and peri-implant health - silver bullet or sham?

Probiotics are thought to be beneficial microbes that influence health-related outcomes through host immunomodulation and modulation of the bacteriome. Its reported success in the treatment of gastrointestinal disorders has led to further research on its potential applicability within the dental field due to similarities such as a polymicrobial aetiology and disease associated microbial-shifts. Although the literature is replete with studies demonstrating its efficacy, the use of probiotics in dentistry continues to polarise opinion. Here, we explore the evidence for probiotics and its effect on periodontal and peri-implant health. MEDLINE, EMBASE, and CENTRAL were systemically searched from June 2010 to June 2020 based on a formulated search strategy. Of 1,956 potentially relevant articles, we selected 27 double-blinded randomised clinical trials in the areas of gingivitis, periodontitis, residual pockets during supportive periodontal therapy, and peri-implant diseases, and reviewed their efficacy in these clinical situations. We observed substantial variation in treatment results and protocols between studies. Overall, the evidence for probiotic therapy for periodontal and peri-implant health appears unconvincing. The scarcity of trials with adequate power and follow-up precludes any meaningful clinical recommendations. Thus, the routine use of probiotics for these purposes are currently unsubstantiated. Further multi-centre trials encompassing a standardised investigation on the most promising strains and administration methods, with longer observation times are required to confirm the benefits of probiotic therapy for these applications.

Impact of systemic probiotics as adjuncts to subgingival instrumentation on the oral-gut microbiota associated with periodontitis: A randomized controlled clinical trial

BACKGROUND

The oral-gut axis may be a route linking periodontal and systemic diseases. Probiotics could be an alternative for the treatment of microbial dysbiotic conditions, including periodontitis. This randomized placebo-controlled clinical trial evaluated the short-term efficacy of systemic probiotics adjunctive to subgingival instrumentation (SI) in promoting a better restoration of the oral-gut microbiotas and greater periodontal clinical outcome.

METHODS

Systemically healthy adults with untreated periodontitis were recruited from a Dental School setting and allocated to receive SI plus placebo (n = 24) or probiotics (n = 24), one capsule/day for 30 days. Subgingival biofilm and stool were obtained at baseline and 2-months post-therapy for microbiological analyses by checkerboard and 16S rRNA gene sequencing. Differences in all parameters between placebo (n = 23) and probiotics (n = 19) groups were assessed by non-parametric tests.

RESULTS

Most subgingival species and α-diversity decreased after therapies (P <0.05), whereas gut composition/diversity were slightly or not affected by treatments. In parallel, significant clinical improvement (P <0.05) was similar between groups, although a trend for a higher proportion of poor responders in the placebo (60.8%) than the probiotic group (31.5%) was observed (P = 0.07). Strong correlations between oral and fecal species were found (P <0.01), and distinct species related to poor response for different therapies (P <0.05). Patients were classified into five periodontitis oral-gut microbial clusters, which correlated differently with attachment loss after therapies (P <0.05).

CONCLUSION

Systemic probiotics combined with SI did not provide short-term additional clinical or microbiological benefits in the treatment of periodontitis; however, response to therapies seemed to correlate with distinct oral-gut microbial profiles.

Treatment challenges and delivery systems in immunomodulation and probiotic therapies for periodontitis

Introduction: Periodontitis is a widespread illness that arises due to disrupted interplay between the oral microbiota and the host immune response. In some cases, conventional therapies can provide temporary remission, although this is often followed by disease relapse. Recent studies of periodontitis pathology have promoted the development of new therapeutics to improve treatment options, together with local application using advanced drug delivery systems.Areas covered: This paper provides a critical review of the status of current treatment approaches to periodontitis, with a focus on promising immunomodulation and probiotic therapies. These are based on delivery of small molecules, peptides, proteins, DNA or RNA, and probiotics. The key findings on novel treatment strategies and formulation of advanced delivery systems, such as nanoparticles and nanofibers, are highlighted.Expert opinion: Multitarget therapy based on antimicrobial, immunomodulatory, and probiotic active ingredients incorporated into advanced delivery systems for application to the periodontal pocket can improve periodontitis treatment outcomes. Translation of such adjuvant therapy from laboratory to patient is expected in the future.

Host Modulation and Treatment of Periodontal Disease

Periodontitis is the sixth-most prevalent disease in the world and the first cause for tooth loss in adults. With focus shifted to the inflammatory/immune response in the pathogenesis of periodontitis, there is a critical need to evaluate host modulatory agents. Synthetic and biological disease-modifying antirheumatic drugs are a cornerstone for the treatment of inflammatory diseases. Recent prospective cohort studies showed that synthetic disease-modifying antirheumatic drugs improved periodontal clinical parameters following nonsurgical periodontal treatment in patients with rheumatoid arthritis. Treatment with recombinant humanized monoclonal antibodies against CD20 (rituximab) and IL-6 receptor (tocilizumab), the latter also in clinical trials for the treatment of COVID-19 pneumonia, resulted in decreased periodontal inflammation and improved periodontal status. Studies on the effect of TNF-α inhibitors in patients with periodontitis yielded inconsistent results. Recent data suggest that probiotics provide anti-inflammatory clinical benefit, as do nutritional supplements, such as n-3 fatty acids, when combined with periodontal therapy. Probiotics reduce the production of proinflammatory cytokines/chemokines by suppressing NF-κB pathways and promote the accumulation of T regulatory cells. Statins, like aspirin, have been shown to exhibit anti-inflammatory and bone-preserving actions by upregulating production of Specialized Proresolving Mediators (SPMs). Currently, there is insufficient scientific support for the topical delivery of statins or bisphosphonates as adjuncts to periodontal therapy. Here, we present a critical review of the most recent host modulatory agents applied in humans and the key immune pathways that they target. Emerging evidence from novel drug candidates, including SPMs and complement inhibitors as previously studied in animal models and currently in human clinical trials, suggests future availability of adjunctive therapeutic strategies for the management of periodontitis.

BSP implementation of European S3 - level evidence-based treatment guidelines for stage I-III periodontitis in UK clinical practice

OBJECTIVES

To adapt the supranational European Federation for Periodontology (EFP) S3-Level Clinical Practice Guideline for treatment of periodontitis (stage I-III) to a UK healthcare environment, taking into account the views of a broad range of stakeholders, and patients.

SOURCES

This UK version is based on the supranational EFP guideline (Sanz et al., 2020) published in the Journal of Clinical Periodontology. The source guideline was developed using the S3-level methodology, which combined the assessment of formal evidence from 15 systematic reviews with a moderated consensus process of a representative group of stakeholders, and accounts for health equality, environmental factors and clinical effectiveness. It encompasses 62 clinical recommendations for the treatment of stage I-III periodontitis, based on a step-wise process mapped to the 2017 classification system.

METHODOLOGY

The UK version was developed from the source guideline using a formal process called the GRADE ADOLOPMENT framework. This framework allows for the adoption (unmodified acceptance), adaptation (acceptance with modifications) and the de novo development of clinical recommendations. Using this framework and following the S3-process, the underlying systematic reviews were updated and a representative guideline group of 75 delegates from 17 stakeholder organisations was assembled into three working groups. Following the formal S3-process, all clinical recommendations were formally assessed for their applicability to the UK and adoloped accordingly.

RESULTS AND CONCLUSION

Using the ADOLOPMENT protocol, a UK version of the EFP S3-level clinical practice guideline was developed. This guideline delivers evidence- and consensus-based clinical recommendations of direct relevance to the dental community in the UK.

CLINICAL SIGNIFICANCE

The aim of S3-level guidelines is to combine the evaluation of formal evidence, grading and synthesis with the clinical expertise of a broad range of stakeholders to form clinical recommendations. Herein, the first major international S3-level guideline in dentistry, the EFP guideline, was implemented for direct clinical applicability in the UK healthcare system.

Clinical effects of probiotic or azithromycin as an adjunct to scaling and root planning in the treatment of stage III periodontitis: a pilot randomized controlled clinical trial

Background

The aim of this triple-blind placebo-controlled parallel-arm randomized clinical trial was to evaluate the clinical effects of Lactobacillus rhamnosus SP1 or azithromycin as an adjunct to scaling and root planing (SRP) in patients with stage III periodontitis.

Methods

Forty-seven systemically healthy participants with stage III periodontitis were recruited. Following SRP, the participants were randomly assigned to one of three treatment modalities; (1) placebo (n = 15), (2) probiotics (n = 16) and (3) antibiotics-azithromycin (n = 16). The participants were monitored at baseline, 3, 6, 9 and 12 months after therapy. Probing pocket depth (PPD), bleeding on probing (BOP), clinical attachment loss (CAL) and plaque accumulation (PI) were evaluated.

Results

All 47 participants completed the study. At 12 months, all groups showed significant improvements of PPD and PI (p < 0.012) irrespective of the treatment modality and without significant differences between the groups. Probiotics and azithromycin showed no added benefit in terms of CAL. While the placebo (p = 0.002) and the antibiotic-azithromycin (p = 0.002) group showed a significant reduction of BOP, only the placebo group revealed a significant reduction of CAL at 12 months follow-up (p = 0.003). The number of sites and teeth with PPD ≥ 5, ≥ 6 and ≥ 7 mm were significantly reduced in all groups at 12 months follow-up (p < 0.025) irrespective of the treatment regime and without significant differences between the groups.

Conclusion

The use of probiotics or azithromycin as an adjunct to SRP failed to provide additional benefits in the treatment of stage III periodontitis. The benefits of these two treatment regimes as an adjunct to SRP remain unclear.

Trial registration

NCT02839408, 10/28/2017, Clinicaltrial.gov.

Metagenomic sequencing provides new insights into the subgingival bacteriome and aetiopathology of periodontitis

"Open-ended" molecular techniques such as 16S rRNA sequencing have revealed that the oral bacteriome of subgingival plaque is more diverse than originally thought. 16S rRNA analysis has demonstrated that constituents of the overall bacterial community are qualitatively similar in health and disease, differing mainly in their relative proportions with respect to each other. Species in low abundance can also act as critical species, leading to the concept of global community dysbiosis which relates to shifts in community structure, rather than shifts in membership. Correlation analysis suggests that coordinated interactions in the community are essential for incipient dysbiosis and disease pathogenesis. The subgingival bacteriome also provides biomarkers that are useful for disease detection and management. Combined with clinical and biological parameters, these may assist clinicians in developing and implementing effective treatment strategies to restore microbial homeostasis and monitor disease. Identification of higher risk groups or poor responders to treatment using unique subgingival bacteriome signatures may also lead to early intervention.

Evidence-based, personalised and minimally invasive treatment for periodontitis patients - the new EFP S3-level clinical treatment guidelines

The 2017 international classification system for periodontal diseases characterises periodontitis patients based upon disease extent, severity and past experience, and in stage IV includes a treatment complexity component. In addition, taking into account well-established risk factors, it aims to estimate the risk for future attachment loss. This classification system draws upon current understanding of disease pathobiology and reflects the complex, multifactorial nature of the periodontitis. It also acknowledges individual patients' risk profiles.Classification and diagnosis are distinct but linked entities, and the inclusion of established risk factors in the system helps signpost the clinician and patient towards a more personalised approach to care provision. The European Federation of Periodontology (EFP) has recently developed an S3-level clinical treatment guideline for stages I to III periodontitis, based upon a rigorous standardised process involving 15 systematic reviews of current evidence and their synthesis by a representative group of experts and stakeholders. The aim is to guide the practitioner through the complex plethora of periodontal management options and to facilitate pragmatic decision-making in full knowledge of the evidence base.Here, we present the structured, stepwise treatment protocols developed by the EFP guideline group and highlight selected specific clinical recommendations. The adapted guidelines for the UK healthcare system will be published in early 2021.

Do Lasers Have an Adjunctive Role in Initial Non-Surgical Periodontal Therapy? A Systematic Review

(1) Background: dental lasers have numerous applications for periodontal therapy which include surgical procedures of soft tissue and osseous structures, and non-surgical treatments such as pathogen reduction, removal of surface accretions, and photobiomodulation. The aim of this review was to evaluate the scientific literature to ascertain whether lasers have a beneficial role when used adjunctively in initial non-surgical periodontal therapy. (2) Methods: A PubMed search was performed specifically for randomized clinical trials where a dental laser was used adjunctively for initial periodontal therapy on human patients published from January 2010–April 2020. The first search identified 1294 eligible studies. After additional criteria and filters were applied, 20 manuscripts were included in this review. (3) Results: The chosen manuscripts reported on investigations into initial therapy for patients diagnosed with chronic periodontitis. After periodontal charting, conventional instrumentation such as hand and ultrasonic scaling was performed on all patients in the studies, and then a test group or groups of patients were treated adjunctively with a laser. That adjunctive laser group’s periodontal findings showed various degrees of improved health compared to the group treated with only conventional methods. (4) Conclusion: This systematic review found that 70% of the included studies reported significantly better outcomes in certain clinical parameters, but no improvement in others. The remaining 30% of the manuscripts reported no significant difference in any of the measurements. With consideration to correct parametry, lasers have an adjunctive role in initial non-surgical periodontal therapy.

Immunomodulatory Properties of Stem Cells in Periodontitis: Current Status and Future Prospective

Periodontitis is the sixth-most prevalent chronic inflammatory disease and gradually devastates tooth-supporting tissue. The complexity of periodontal tissue and the local inflammatory microenvironment poses great challenges to tissue repair. Recently, stem cells have been considered a promising strategy to treat tissue damage and inflammation because of their remarkable properties, including stemness, proliferation, migration, multilineage differentiation, and immunomodulation. Several varieties of stem cells can potentially be applied to periodontal regeneration, including dental mesenchymal stem cells (DMSCs), nonodontogenic stem cells, and induced pluripotent stem cells (iPSCs). In particular, these stem cells possess extensive immunoregulatory capacities. In periodontitis, these cells can exert anti-inflammatory effects and regenerate the periodontium. Stem cells derived from infected tissue possess typical stem cell characteristics with lower immunogenicity and immunosuppression. Several studies have demonstrated that these cells can also regenerate the periodontium. Furthermore, the interaction of stem cells with the surrounding infected microenvironment is critical to periodontal tissue repair. Though the immunomodulatory capabilities of stem cells are not entirely clarified, they show promise for therapeutic application in periodontitis. Here, we summarize the potential of stem cells for periodontium regeneration in periodontitis and focus on their characteristics and immunomodulatory properties as well as challenges and perspectives.

Treatment of stage I-III periodontitis-The EFP S3 level clinical practice guideline

BACKGROUND

The recently introduced 2017 World Workshop on the classification of periodontitis, incorporating stages and grades of disease, aims to link disease classification with approaches to prevention and treatment, as it describes not only disease severity and extent but also the degree of complexity and an individual's risk. There is, therefore, a need for evidence-based clinical guidelines providing recommendations to treat periodontitis.

AIM

The objective of the current project was to develop a S3 Level Clinical Practice Guideline (CPG) for the treatment of Stage I-III periodontitis.

MATERIAL AND METHODS

This S3 CPG was developed under the auspices of the European Federation of Periodontology (EFP), following the methodological guidance of the Association of Scientific Medical Societies in Germany and the Grading of Recommendations Assessment, Development and Evaluation (GRADE). The rigorous and transparent process included synthesis of relevant research in 15 specifically commissioned systematic reviews, evaluation of the quality and strength of evidence, the formulation of specific recommendations and consensus, on those recommendations, by leading experts and a broad base of stakeholders.

RESULTS

The S3 CPG approaches the treatment of periodontitis (stages I, II and III) using a pre-established stepwise approach to therapy that, depending on the disease stage, should be incremental, each including different interventions. Consensus was achieved on recommendations covering different interventions, aimed at (a) behavioural changes, supragingival biofilm, gingival inflammation and risk factor control; (b) supra- and sub-gingival instrumentation, with and without adjunctive therapies; (c) different types of periodontal surgical interventions; and (d) the necessary supportive periodontal care to extend benefits over time.

CONCLUSION

This S3 guideline informs clinical practice, health systems, policymakers and, indirectly, the public on the available and most effective modalities to treat periodontitis and to maintain a healthy dentition for a lifetime, according to the available evidence at the time of publication.

Effect of topical administration of propolis in chronic periodontitis

To investigate the effect of topical administration of propolis (a honeybee product) or curry leaf (an herbal product) into the periodontal pockets of periodontitis patients, a double-blind controlled clinical trial was conducted with 24 subjects including one drop-out diagnosed with moderate-to-advanced chronic periodontitis who completed initial periodontal therapy. They were randomly allocated to the following treatments: placebo, propolis, curry leaf, and minocycline. Gingival crevicular fluid (GCF) samples collected before and after the intervention were analyzed to quantify the number of total bacteria and number of six major periodontopathic bacteria by real-time PCR. Periodontitis-related clinical parameters were also analyzed. Among the six propolis-treated patients whose GCF samples were P. gingivalis-positive, three patients converted to be P. gingivalis-negative after the intervention. The minocycline-treated group exhibited a decrease in probing pocket depth (PPD) with statistically significant improvement, but not gain of clinical attachment level (CAL). Both PPD and CAL have been improved in the propolis-treated group at a statistically significant level, but not the curry leaf-treated group. In conclusion, treatment with propolis significantly improved both PPD and CAL, together with a tendency towards reduced P. gingivalis burden in GCF. It is likely that a propolis-based therapy becomes an alternative treatment option for chronic periodontitis during supportive periodontal therapy.